Mommy's First and Last Name

Daddy's/Partners First and Last Name

Phone Number

Mommy's Email Address

Mailing Address

Address Line 2

City

State (2 letter abbreviation)

Zip

Address where services will be performed: Address where services will be performed: check box if different than Mailing address.

Home Address

Address Line 2

City

State (2 letter abbreviation)

Zip

Occupation of both parents/partners

How would you describe your personality?

How would you describe your partner's personality?

Describe how you would like your Baby Nurses interaction with you to develop? For example: Stay in the background except to bring you baby and fix meals, or be more a part of the family in your space always available to answer questions. Sit with you while you breastfeed, or bring you baby and leave you on your own.

Date services will most likely be needed.

How Long will your Baby Nurse be Needed? How Long will your Baby Nurse be Needed?2 weeks3 weeks4 weeks6 weeksother

Other Time Needed (up to 6 months)

Babies Name

Siblings Names & Ages:

Pets (cat/dog) & Names:

What things would be the most helpful to you while your Baby Nurse is in your home?

Over the next four questions select the following items for order of importance: 1 – Breastfeeding assistance 2 – Getting the baby on a Schedule 3 – Sleep and Recovery for Mommy 4 – Help with meals. ----- Please select the FIRST most important item. Over the next four questions select the following items for order of importance: 1 – Breastfeeding assistance 2 – Getting the baby on a Schedule 3 – Sleep and Recovery for Mommy 4 – Help with meals. ----- Please select the FIRST most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

SECOND most important item. SECOND most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

THIRD most important item. THIRD most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

FOURTH most important item. FOURTH most important item. Breastfeeding assistance Getting the baby on a Schedule Sleep and Recovery for Mommy Help with meals

How Did you find out about Our services? Please be as specific as possible!

Have you ever used a Professional child care provider (Nanny/Baby Nurse etc.) in the past? If so, what was you experience like?

Do you have a housekeeping service? Do you have a housekeeping service? Yes No

How frequently? How frequently? Daily Weekly Every 2 weeks Monthly

Anything else that you want to tell us?

Terms of Service – Terms of Service – Your Infant Caregiver will not give medical advice or treatment to baby, mother, or anyone else. We are not Qualified to give such advice. However, they will answer your questions according to their opinion from their experience and education in new mother and infant care. Rachel's Infant Care is a Postpartum Recovery Care Placement Agency. We charge a non-refundable placement fee for our placement services. We do our best to get your chosen Caregiver to you within 48 hours of your discharge from the hospital. If your Caregiver is not available, we will set you up with another Caregiver as quickly as possible. If we do not have a replacement caregiver available the Placement fee will be refunded within 30 days. Caregiver travel is $0.55 a mile round trip (to and from your home) OR round trip airfare plus $100. There is an eight (8) day minimum (for most services, but not all) which you will be charged a per day rate (Call Rachel to find out your per day rate - 770.597.8330) to be paid in prearranged increments. Your Caregiver is NOT a maid. The Caregiver’s job description is on our home page. If you choose to have her do heavy housework like cleaning the bathrooms, Rachel's Infant Care will contact you with additional charges. We the parents will not sue the Caregiver or Rachel's Infant Care (Rachel's Infant Nursing & Postpartum Care, LLC) if an accident occurs while they are in our home. Yes, I agree Terms of Service – Terms of Service – Your Infant Caregiver will not give medical advice or treatment to baby, mother, or anyone else. We are not Qualified to give such advice. However, they will answer your questions according to their opinion from their experience and education in new mother and infant care. Rachel's Infant Care is a Postpartum Recovery Care Placement Agency. We charge a non-refundable placement fee for our placement services. We do our best to get your chosen Caregiver to you within 48 hours of your discharge from the hospital. If your Caregiver is not available, we will set you up with another Caregiver as quickly as possible. If we do not have a replacement caregiver available the Placement fee will be refunded within 30 days. Caregiver travel is $0.55 a mile round trip (to and from your home) OR round trip airfare plus $100. There is an eight (8) day minimum (for most services, but not all) which you will be charged a per day rate (Call Rachel to find out your per day rate - 770.597.8330) to be paid in prearranged increments. Your Caregiver is NOT a maid. The Caregiver’s job description is on our home page. If you choose to have her do heavy housework like cleaning the bathrooms, Rachel's Infant Care will contact you with additional charges. We the parents will not sue the Caregiver or Rachel's Infant Care (Rachel's Infant Nursing & Postpartum Care, LLC) if an accident occurs while they are in our home. Yes, I agree Yes, I agree